whakarāpopototanga
Kua mahi tahi te Kaunihera Whakaoraora o Ūropi (ERC) me te Rōpū Rongoā Tiaki Matea o Ūropi (ESICM) ki te whakawhanake i ēnei aratohu tiaki i muri i te whakaoraora mō ngā pakeke, e ai ki te Whakaaetanga ā-Ao mō te Pūtaiao me te Maimoatanga o te CPR o te tau 2020. Ko ngā kaupapa e kapi ana ko te mate hopuhopu ngākau muri i te hopuhopu ngākau, te tautuhi i ngā take o te hopuhopu ngākau, te whakahaere hāora me te hauhautanga, te werohanga o te uaua o te ngākau, te aroturuki me te whakahaere i te hemodynamic, te whakahaere i te hopuhopu, te whakahaere i te pāmahana, te whakahaere tiaki nui whānui, te matapae, ngā putanga mō te wā roa, te whakaora, me te tuku okana.
Ngā Kupumatua: Te hopukanga o te ngākau, te tiaki whakaora i muri i te pokanga, te matapae, ngā aratohu
Kupu Whakataki me te whānuitanga
I te tau 2015, i mahi tahi te European Resuscitation Council (ERC) me te European Society of Critical Care Medicine (ESICM) ki te whakawhanake i ngā aratohu tiaki tuatahi i muri i te whakaora, i whakaputaina ki roto i te Resuscitation and Critical Care Medicine. I whakahoutia whānuitia ēnei aratohu tiaki i muri i te whakaora i te tau 2020, ā, i whakaurua hoki ngā pūtaiao kua whakaputaina mai i te tau 2015. Ko ngā kaupapa i hipokina ko te mate hopuhopu muri i te manawa, te whakahaere hāora me te hauhautanga, ngā whāinga hemodynamic, te werohanga coronary, te whakahaere pāmahana kua arotahihia, te whakahaere hopuhopu, te matapae, te whakaora, me ngā putanga roa (Pikitia 1).
Whakarāpopototanga o ngā huringa nui
Te tiaki tonu i muri i te whakaoranga:
• Ka tīmata tonu te maimoatanga i muri i te whakaoranga i muri i te ROSC (te whakaoranga o te tohanga toto), ahakoa te wāhi (Pikitia 1).
• Mō te hopukanga o te ngakau i waho o te hōhipera, whakaarohia te haere ki tētahi pokapū hopukanga o te ngakau. Tātarihia te pūtake o te hopukanga o te ngakau.
• Mena he tohu haumanu (hei tauira, te kore pumau o te toto) he tohu ECG rānei mō te ischemia myocardial, ka mahia tuatahitia te angiography coronary. Mena kāore e kitea te pūtake o te whara e te angiography coronary, ka mahia te CT encepography me/ranei te CT pulmonary angiography.
• Ka taea te tautuhi wawe i ngā mate manawa, mate pūnaha io rānei mā te mahi i ngā matawai CT o te roro me te uma i te wā e noho ana ki te hōhipera, i mua atu, i muri rānei i te angiography coronary (tirohia te Coronary Reperfusion).
• Whakahaerehia he CT o te roro me/ranei he angiography o ngā pukahukahu mēnā he tohu, he tohu rānei e tohu ana i tētahi take pūnaha io, manawa rānei i mua i te asystole (hei tauira, te ānini, te mate haurangi, ngā ngoikoretanga pūnaha io, te poto o te manawa, te hypoxemia rānei kua tuhia ki ngā tūroro e mōhiotia ana he mate manawa).
1. Te ara manawa me te manawa
Kua whakahokia mai te whakahaere o te ara manawa i muri i te tohanga toto ohorere
• Me haere tonu te tautoko i te ara manawa me te manawa i muri i te whakaoranga o te tohanga toto ohorere (ROSC).
• Ko ngā tūroro kua pāngia e te mate manawa poto, kua hoki wawe mai ki te mahi noa o te roro, ā, kua manawa noa, kāore pea e hiahiatia he whakaurunga ngongo endotracheal, engari me hoatu he hāora mā te kopare mēnā he iti iho i te 94% te nui o te hāora o te uaua.
• Me mahi te whakaurunga o te ngongo endotracheal ki ngā tūroro e noho moe ana i muri i te ROSC, ki ngā tūroro rānei he tohu haumanu kē atu mō te whakamoe me te manawa miihini, mēnā kāore e mahia te whakaurunga o te ngongo endotracheal i te wā o te CPR.
• Me mahi te whakaurunga o te ngongo endotracheal e te kaiwhakahaere mohio, ā, he nui te angitu.
• Me whakaū te tūnga tika o te ngongo endotracheal mā te whakamahi i te kapnography waveform.
• Ki te kore he taputapu whakapūmau endotracheal mātau, he mea tika kia whakauruhia he ara manawa supraglottic (SGA) kia mau tonu rānei te ara manawa mā te whakamahi i ngā tikanga taketake kia tae rā anō ki te wā e wātea mai ai he taputapu whakapūmau.
Whakahaere hāora
• Whai muri i te ROSC, ka whakamahia te hāora 100% (te nui rawa rānei e wātea ana) kia taea rā anō te ine pono i te kukū o te hāora uaua, te pēhanga wāhanga rānei o te hāora uaua.
• Kia taea te ine pono i te mākū o te hāora toto, kia taea rānei te whiwhi i te uara hau toto toto, ka whakatōpūhia te hāora i whakaohokia kia eke ki te mākū o te hāora toto o te 94-98%, ki te pēhanga hāora ā-wāhanga toto rānei (PaO2) o te 10 ki te 13 kPa, 75 ki te 100 mmHg rānei (Pikitia 2).
• 避免ROSC后的低氧血症(PaO2 <8 kPa或60 mmHg).
• Āraia te hyperxemia i muri i te ROSC.
Whakahaere hauhautanga
• Tikina ngā hau toto uaua, ā, whakamahia te aroturuki i te CO2 i te mutunga o te tai mō ngā tūroro e whakamahi ana i te manawa miihini.
• Mō ngā tūroro e hiahia ana ki te whakapūngao ā-ringa i muri i te ROSC, whakatikatikahia te whakapūngao kia eke ki te pēhanga ā-wāhanga noa o te hauhā waro (PaCO2) o te 4.5 ki te 6.0 kPa, 35 ki te 45 mmHg rānei.
• He maha ngā wā ka aroturukitia te PaCO2 i roto i ngā tūroro e rongoatia ana me te whakahaere pāmahana kua arotahihia (TTM) nā te mea ka puta pea te hypocapnia.
• Ka inehia ngā uara hau toto mā te whakamahi i ngā tikanga whakatikatika pāmahana, kore rānei i te pāmahana i te wā o te TTM me ngā pāmahana iti.
• Whakamahia he rautaki whakapūhauora tiaki-pūkahukahu kia eke ai ki te rōrahi tai o te 6 – 8 ml/kg o te taumaha tinana tino pai.
2. Te tohanga toto o te korokoro
Te whakahokinga mai o te toto
• Me arotake tere te taiwhanga whakatārewatanga o te ngākau i ngā tūroro pakeke e pāngia ana e te ROSC whai muri i te whakapae kua hopukanga te ngākau me te pikinga o te wāhanga ST i runga i te ECG (me mahi tonu te PCI mēnā e tika ana).
• Me whai whakaaro ki te aromatawai taiwhanga whakauru catheter ngākau tere mō ngā tūroro ROSC kua pāngia e te mate ngākau (OHCA) i waho o te hōhipera, kāore he pikinga o te wāhanga ST i runga i te ECG, ā, e kiia ana he nui te tūponotanga o te aukati tere o te uaua coronary (hei tauira, ngā tūroro he koretake te haemodynamic me/ranei te hiko).
Te aroturuki me te whakahaere i te haemodynamic
• Me aroturuki tonu te toto toto i roto i te ductus arteriosus mō ngā tūroro katoa, ā, he mea tika te aroturuki i te putanga o te ngakau mō ngā tūroro kāore i te pumau te toto.
• Whakahaerehia he echocardiogram i te wā wawe tonu (i te wā e taea ai) mō ngā tūroro katoa hei tautuhi i ngā āhuatanga o te ngākau me te ine i te nui o te ngoikore o te uaua ngākau.
• Āraia te whakaheke toto (< 65 mmHg). Whaia te pēhanga toto toharite (MAP) kia eke ki te putanga mimi e tika ana (> 0.5 mL/kg*h me te lactate noa, iti iho rānei (Pikitia 2).
• Kāore e taea te waiho i te Bradycardia kia rongoātia i te wā o te TTM i te 33°C mēnā he rawaka te toto toto, te lactate, te ScvO2, te SvO2 rānei. Ki te kore, whakaarohia te whakanui ake i te pāmahana ūnga, engari kaua e neke ake i te 36°C.
• Te pupuri i te rere o te toto mā te whakamahi i ngā wai, te norepinephrine, me/ranei te dobutamine, i runga i te hiahia mō te rōrahi o roto i ngā oko toto, te whakawhāiti i te toto, te whakaheke rānei i te uaua o ia tūroro.
• Āta karohia te hypokalemia, e pā ana ki ngā arrhythmias ventricular.
• Mena kāore i te rawaka te whakaora wai, te whakaheke uaua, me te rongoā vasoactive, ka whakaarohia pea te tautoko tohanga toto ā-ringa (hei tauira, te papu poihau intra-aortic, te taputapu āwhina ventricle maui, te whakahāngai hāora ki te membrane arteriovenous extracorporeal rānei) hei rongoā mō te ohorere cardiogenic pumau nā te ngoikore o te ventricle maui. Me whakaaro anō hoki ki ngā taputapu āwhina ventricle maui, te whakahāngai hāora endovascular extracorporeal rānei mō ngā tūroro e pāngia ana e te haemodynamically unstable acute coronary syndrome (ACS) me te ventricular tachycardia (VT) recurrent ventricular fibrillation (VF) ventricular fibrillation (VF) rānei, ahakoa ngā kōwhiringa maimoatanga pai rawa atu.
3. Te mahi ā-nekehanga (te whakapai ake i te whakaora io)
Whakahaerehia ngā hopukanga
• Ka tūtohu mātou kia whakamahia te electroencephalogram (EEG) hei tātaritanga i ngā electrospasms i roto i ngā tūroro e pāngia ana e ngā ruku haumanu, me te aroturuki i te urupare ki te maimoatanga.
• Hei rongoā i ngā mate haurangi i muri i te hopukanga o te ngakau, ka tūtohu mātou i te levetiracetam, te sodium valproate rānei hei rongoā ārai haurangi tuatahi, hei tāpiri atu ki ngā rongoā whakangāwari.
• Ka tūtohu mātou kia kaua e whakamahia he ārai mate haurangi noa mō ngā tūroro whai muri i te hopukanga o te ngakau.
Whakahaere pāmahana
• Mō ngā pakeke kāore e aro ki te OHCA, ki te hopukanga ngakau rānei i te hōhipera (tetahi manawataki ngakau tuatahi), ka tūtohu mātou kia whakahaerea te pāmahana kua arotahihia (TTM).
• Kia mau tonu te pāmahana ūnga i waenga i te 32 me te 36 °C mō te 24 hāora pea.
• Mō ngā tūroro e noho pōrearea ana, karohia te kirika (> 37.7°C) mō te 72 hāora pea i muri i te ROSC.
• Kaua e whakamahia he wai makariri ā-uaua i mua i te hōhipera hei whakaheke i te pāmahana o te tinana. Te Whakahaere Tiaki Kaha Whānui – Te whakamahi i ngā rongoā whakangāwari me ngā opioids poto te mahi.
• Kāore e whakaaetia te whakamahi i ngā rongoā aukati uaua-io i ngā tūroro e pāngia ana e te TTM, engari ka taea te whakaaro mēnā he tino makariri te tinana i te wā o te TTM.
• He mea noa te whakarato i te ārai mate pāwera ki ngā tūroro e pāngia ana e te mate manawa.
• Te ārai i te toto toto hohonu.
• 如果需要，使用胰岛素输注将血糖定位为7.8-10 mmol/L（140- 180 mg/dL），避免低（mmol/糉<4.0 mg/dL).
• Tīmatahia ngā whāngai puku iti (whāngai kai) i te wā TTM, ā, whakanuia ake i muri i te whakamahana anō mēnā e tika ana. Mēnā ka whakamahia he TTM 36°C hei pāmahana ūnga, ka piki ake pea te auau whāngai puku i mua ake i te wā TTM.
• Kāore mātou e tūtohu i te whakamahinga auau o ngā paturopi ārai mate.
4. Matapae tuku iho
Ngā aratohu whānui
• Kāore mātou e tūtohu i ngā paturopi ārai mate mō ngā tūroro kāore i te mōhio i muri i te whakaoranga mai i te hopukanga o te ngākau, ā, me whakahaere te neuroprognosis mā te whakamātautau haumanu, te electrophysiology, ngā biomarkers, me te whakaahua, hei whakamōhio i ngā whanaunga o te tūroro, hei āwhina hoki i ngā tākuta ki te arotahi i te maimoatanga i runga i ngā tūponotanga o te tūroro ki te whakatutuki i te whakaoranga neurological whai tikanga (Pikitia 3).
• Kāore he matapae kotahi e 100% te tika. Nō reira, ka tūtohu mātou i tētahi rautaki matapae io maha-ara.
• Ina matapaetia ngā putanga io kino, me tino tika te matapae me te tino motuhake hei karo i ngā matapae rūpahu.
• He mea nui te whakamātautau haumanu io mō te matapae. Hei karo i ngā matapae pōuri, me karo ngā tākuta i ngā whakapoauau pea o ngā hua whakamātautau ka whakapoauauhia e ngā rongoā whakamoe me ētahi atu rongoā.
• E taunakihia ana te tirotiro haumanu i ia rā ina rongoatia ngā tūroro ki te TTM, engari me whakahaere te aromatawai whakamutunga mō te matapae i muri i te whakamahana anō.
• Me mōhio ngā tākuta ki te mōrearea o te whakaaro matapae i puta mai i a rātou anō, ka puta mai ina whakamahia ngā hua o te whakamātautau taupū e tohu ana i ngā putanga kino i roto i ngā whakataunga maimoatanga, inā koa mō ngā maimoatanga e mau tonu ai te ora.
• Ko te kaupapa o te whakamātautau Neuroprognosis Index he aromatawai i te kaha o te whara roro hypoxic-ischemic. Ko te neuroprognosis tētahi o ngā āhuatanga maha hei whakaaroaro ina matapakihia te pūmanawa o te tangata ki te whakaora.
Matapae maha-tauira
• Tīmatahia te aromatawai matapae mā te whakamātautau haumanu tika, ā, ka mahia i muri i te whakakorenga o ngā āhuatanga whakararuraru nui (hei tauira, te whakamoe toenga, te hypothermia) (Pikitia 4)
• I te korenga o ngā mea whakapoauau, ko ngā tūroro e moe ana me te ROSC ≥ M≤3 i roto i ngā haora 72 ka pāngia e ngā hua kino mēnā e rua, neke atu rānei o ngā tohu e whai ake nei: kāore he whakaata kanohi o te kanohi i te ≥ 72 haora, te ngaronga o te N20 SSEP i ngā taha e rua ≥ 24 haora, te EEG teitei > 24 haora, te enolase neuronal motuhake (NSE) > 60 μg/L mō te 48 haora me/ranei 72 haora, te myoclonus āhua ≤ 72 haora, te CT roro horapa, te MRI me te whara hypoxic whānui rānei. Ko te nuinga o ēnei tohu ka taea te tuhi i mua i te 72 haora o te ROSC; Heoi, ka aromatawaitia noa ō rātou hua i te wā o te aromatawai matapae haumanu.
Whakamātautau haumanu
• Ka taea te whakararuraru i te whakamātautau haumanu e ngā rongoā whakamoe, ngā opioid, ngā rongoā whakangāwari uaua rānei. Me whai whakaaro tonu ki ngā āhuatanga whakararuraru pea nā te toenga o te rongoā whakamoe, ā, me whakakore atu.
• Mō ngā tūroro e noho pōrearea ana mō ngā haora 72, i muri rānei i te ROSC, ka tohu pea ēnei whakamātautau i tētahi matapae kino ake mō te pūnaha io.
• Mō ngā tūroro e noho moe ana i muri i ngā hāora 72, i muri rānei i te ROSC, ka taea e ngā whakamātautau e whai ake nei te tohu i ngā putanga kino o te pūnaha io:
– Te ngaro o ngā whakaata mārama o te kamo o ngā kanohi e rua
– Te ine ira o te tamaiti
– Te ngaronga o te aro o te kornea i ngā taha e rua
– Te myoclonus i roto i ngā hāora 96, inā koa te myoclonus i roto i ngā hāora 72
Ka tūtohu hoki mātou kia tuhia he EEG i te wā e kitea ana ngā tics myoclonic kia kitea ai ngā mahi epileptiform e pā ana, kia tautuhia rānei ngā tohu EEG, pērā i te urupare papamuri, te haere tonu rānei, e tohu ana i te pūmanawa ka taea te whakaora i te pūnaha io.
te pūtaiao roro
• Ka mahia te EEG (electroencephalogram) i ngā tūroro e ngaro ana te mārama i muri i te hopukanga o te ngakau.
• Ko ngā tauira EEG tino kino ko ngā papamuri pehi me te kore rānei o ngā tukunga manawa ā-wā me te pehitanga pakū. Ka tūtohu mātou kia whakamahia ēnei tauira EEG hei tohu mō te matapae kino i muri i te mutunga o te TTM me muri i te whakamoe.
• Ko te kitea o ngā mate hopuhopu i runga i te EEG i ngā haora 72 tuatahi i muri i te ROSC he tohu mō te matapae kino.
• Ko te kore o te urupare papamuri i runga i te EEG he tohu mō te matapae kino i muri i te hopukanga o te ngakau.
• Ko te ngaronga o te pūmanawa N20 cortical i puta mai i ngā somatosensory e rua ngā taha he tohu mō te matapae kino i muri i te hopukanga o te ngakau.
• He maha ngā wā ka whakaarohia ngā hua o te EEG me ngā somatosensory evoked potentials (SSEP) i roto i te horopaki o te whakamātautau haumanu me ētahi atu whakamātautau. Me whai whakaaro ki ngā rongoā aukati neuromuscular ina whakahaerehia te SSEP.
Ngā Tohu Koiora
• Whakamahia he whānuitanga o ngā inenga NSE me ētahi atu tikanga hei matapae i ngā putanga i muri i te hopukanga o te ngākau. Ko ngā uara teitei i te 24 ki te 48 hāora, 72 hāora rānei, me ngā uara teitei i te 48 ki te 72 hāora, e tohu ana i te matapae kino.
Whakaahua
• Whakamahia ngā rangahau whakaahua roro hei matapae i ngā putanga kino o te pūnaha io i muri i te hopukanga o te ngakau me ētahi atu matapae i roto i ngā pokapū whai wheako rangahau e tika ana.
• Ko te kitea o te pupuhi roro whānui, e whakaatuhia ana e te hekenga nui o te ōwehenga hina/mā i runga i te CT roro, te herenga whānui rānei o te horapa i runga i te MRI roro, e tohu ana i te kino o te matapae io i muri i te hopukanga o te ngakau.
• He maha ngā wā ka whakaarohia ngā kitenga whakaahua me ētahi atu tikanga hei matapae i te matapae o te mate io.
5. Kati te maimoatanga e ora ai te tangata
• He kōrero motuhake mō te aromatawai i te matapae o te tango me te whakaora io o te rongoā tautoko-ora (WLST); Me whai whakaaro te whakatau ki te WLST ki ngā āhuatanga ehara i te whara roro, pērā i te tau, te mate tāpiri, te mahi a ngā okana pūnaha, me te kōwhiringa tūroro.
Whakaritea he wā e tika ana mō te whakawhitiwhiti kōrero, me te matapae mō te wā roa i muri i te hopukanga o te ngakau
Ko te taumata o te maimoatanga i roto i te tīma e whakatau ana, ā, • ka whakahaerehia ngā aromatawai mahi ā-tinana, ā-kore-whānau hoki me ngā whanaunga. Te kimi wawe i ngā matea whakaora mō ngā ngoikoretanga tinana i mua i te tukunga atu ki te hōhipera, me te whakarato i ngā ratonga whakaora ina hiahiatia. (Pikitia 5).
• Whakaritea ngā haerenga tirotiro mō ngā morehu katoa o te mate ngakau i roto i ngā marama e 3 o te tukunga atu ki te hōhipera, tae atu ki ēnei e whai ake nei:
- 1. Tātarihia ngā raruraru hinengaro.
2. Tirohia mēnā he raruraru wairua me te ngenge.
3. Hoatu he mōhiotanga me te tautoko ki ngā morehu me ngā whānau.
6. Te tuku okana
• Me tutuki ngā whakataunga katoa e pā ana ki te tuku okana ki ngā whakaritenga ture me ngā tikanga matatika ā-rohe.
• Me whai whakaaro ki te tuku okana mō te hunga e tutuki ana i te ROSC me ngā paearu mō te mate pūnaha io (Pikitia 6).
• Mō ngā tūroro e whakapūnga ana i te manawa i roto i te pō, engari kāore e tutuki i a rātou ngā paearu mō te mate pūnaha io, me whakaaro ki te tuku okana i te wā e mutu ai te rere o te toto mēnā kua whakatauhia kia tīmata te maimoatanga i te mutunga o te oranga, kia mutu ai hoki te tautoko ora.
Te wā tuku: Hurae-26-2024